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ACP HospitalistWeekly 7-14-10
Highlights
Critical care
- Weekend ICU admissions may be associated with higher mortality rates
Patient communication
- Cancer diagnoses often given quickly, impersonally
From ACP Hospitalist
- Send us your coding questions
- Last chance: Suggest a colleague as a Top Hospitalist
Cartoon caption contest
- Put words in our mouth
Physician editor: A. Scott Keller, FACP
Highlights
.Hospitals improving PCI, MI outcomes
Hospitals across the country are seeing improvements in caring for patients experiencing myocardial infarction (MI) or undergoing percutaneous coronary intervention (PCI), according to registry data.
The American College of Cardiology Foundation’s National Cardiovascular Data Registry (NCDR) involves more than 2,400 hospitals and more than 10.6 million patient records. A full analysis will appear in the July 20 issue of the Journal of the American College of Cardiology.
A myocardial infarction study group consisted of nearly 132,000 patients treated for a heart attack at approximately 250 participating hospitals from January 2007 through June 2009. The data analysis showed significant improvements in several key aspects of heart attack care, including:
- an increase from 90.8% to 93.8% in the use of treatments to restore blood flow to the heart in patients with ST-elevated MI (STEMI),
- an increase from 64.5% to 88% in the number of patients with STEMI heart attacks treated with PCI within 90 minutes of arriving at the hospital, a key quality benchmark,
- an improvement from 89.6% to 92.3% in overall performance scores that measure timeliness and appropriateness of therapy for STEMI heart attacks,
- an improvement in achieving correct dosing of several types of blood thinners among non-STEMI patients,
- a reduction from 6.2% to 5.5% in risk-adjusted hospital death rates among STEMI patients and from 4.3% to 3.9% among NSTEMI patients, and
- an improvement in prescribing guideline-recommended medications, including aspirin, clopidogrel, statins, beta blockers and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, as well as in counseling patients to stop smoking and referring patients to cardiac rehabilitation.
A PCI study group consisted of more than 1.7 million patients who'd underwent a procedure from January 2005 through June 2009. During that time, participating hospitals grew from 436 to 959.
The data analysis revealed:
- an increase in procedural complexity, including treatment of significantly more patients with challenging type C lesions (which include diffuse, tortuous, and sharply angulated lesions),
- a reduction in complications related to bleeding or injury to the arteries used for passing tubes to the heart,
- changes in the use of medications designed to prevent unwanted blood clots, reflecting the results of recent clinical trials and recommendations from new clinical practice guidelines, and
- a reduction in the overall use of drug-eluting stents, partially balanced by increased use of new types of drug-eluting stents.
The analysis also highlights specific areas in need of improvement and identifies targets for future research, particularly those aimed at reducing the bleeding risk associated with even the best therapies.
.More patients die from medication errors in July
The rate of fatal medication errors in teaching hospitals spikes almost every July, a finding that can be likely tied to the arrival of new residents, according to a new study.
Researchers examined all U.S. death certificates issued between 1979 and 2006, focusing on the almost 250,000 that were attributed to medication errors. The number of deaths observed during the month of July was compared with what would have been expected, based on the deaths that occurred during other months of the year. The study appears in the July issue of the Journal of General Internal Medicine.
Overall during the time period, and for 21 of the 28 studied years, fatal medication errors spiked by an average of 10% during July. The increase was found only in U.S. counties that had teaching hospitals, and not for any cause of death other than medication errors. The study also found no reduction in the July spike after 2003, when resident work hours were reduced.
The authors looked at a number of alternate explanations before concluding that new medical residents were the most likely cause of the July spike. They noted that the number of inpatient admissions is lower in July, and that any behavioral or societal cause of the medication errors (such as greater alcohol consumption) would affect all counties, rather than just those with teaching hospitals.
Further research is needed to answer remaining questions about the specific mechanisms causing the July spike and to determine why there’s no similar increase in surgical errors, the study authors suggested. Still, the results indicate that medical educators should re-evaluate the responsibilities assigned to new residents, increase supervision of them, and provide more education about medication safety, the authors concluded.
Critical care
.Weekend ICU admissions may be associated with higher mortality rates
Patients admitted to the ICU on a weekend may be 8% more likely to die, but overnight admissions face no significantly higher risk, according to a meta-analysis.
Researchers performed a systematic review to examine whether ICU admission at night or on weekends, when less staff are present, is associated with worse outcomes in the critically ill. Studies that evaluated the association between admission time and outcomes and adjusted for disease severity were included, while those that looked at pediatric patients and those not admitted to the ICU were excluded. Overall, the authors examined 10 studies, eight of which looked at nighttime admissions and six of which looked at weekend admissions. The study results appear in the July Chest.
Eight studies totaling 135,220 patients evaluated daytime/nighttime admissions. The death rates were 21.4% among 73,676 daytime admissions and 20.8% among 61,544 nighttime admissions. The adjusted odds of death was odds ratio [OR] 1.0 (95% confidence interval [CI], 0.87-1.17; P=0.956) between day and night admissions.
A subgroup analysis was done of studies involving intensivist physicians on-site during off-hours. Odds ratios were calculated by study stratification: no intensivist (OR, 1.05; 95% CI, 0.79-1.41; P=0.73), heterogeneity P<.001; intensivist (OR, 0.93; 95% CI, 0.87-0.99; P=0.02), heterogeneity P=0.558; and information not available (OR, 1.02; 95% CI, 0.96-1.09; P=0.44).
Six studies of 180,600 patients evaluated weekday/weekend admissions. The death rate was 11.1% among 133,150 weekday admissions and 15.6% among 47,450 weekend admissions (OR, 1.08 [95% CI, 1.04-1.13]; P<0.001).
A subgroup analysis stratified studies according to the presence of an intensivist physician on-site over the weekend. Again, odds ratios were calculated for death in patients admitted during weekends according to study stratification: no intensivist (OR, 1.07; 95% CI, 0.99-1.15; P=0.081), heterogeneity P=0.319; intensivist (OR, 1.03; 95% CI, 0.61-1.73; P=0.916); and information not available (OR, 1.09; 95%, CI, 1.04-1.15; P=0.001).
The authors concluded that weekend ICU admission was linked to 8% higher mortality rates with sampling variability of 4% to 13%, likely related to changes in organizational/staffing structure of ICUs and hospitals over the weekend. Other possible contributing factors include a decreased physician-to-patient ratio, unavailability of board-certified intensivists, physician fatigue, and difficulty in obtaining complex diagnostic tests or therapies. Limitations include that one study dominated the meta-analysis, and that the control group in that study included admissions only Tuesdays through Thursdays.
Patient communication
.Cancer diagnoses often given quickly, impersonally
Almost 20% of cancer patients are informed of their diagnosis over the phone, and almost half are told in a conversation lasting less than 10 minutes, according to a recent survey.
The data were gathered from a questionnaire given to 460 oncology patients being treated at the National Institutes of Health (NIH) Clinical Center in Bethesda, Md. The surveyed patients had been referred to the NIH from around the U.S. and some foreign countries, and slightly more than a third of them had lymphoma and leukemia. Another 22% had brain cancer, 14% had prostate cancer and 27% had some other type of cancer.
More than half of the patients (54%) reported learning of their cancer diagnosis in a physician’s office, while 18% learned over the phone and 28% were told in the hospital. Of the patients who were diagnosed in the hospital, 43% got the news in their room, 23% in the emergency department, 13% in the recovery room, 7% in the radiology department and 13% in other locations, including one patient who discovered the diagnosis by reading a radiology report.
As for the length of the conversation, 8% said it was less than a minute, 36% between 1 and 10 minutes, and 35% 11 to 30 minutes. About 30% of patients said there was no discussion of treatment options. The survey also asked how satisfied patients were with the way they were informed, and being informed in person and during a longer discussion was associated with greater satisfaction. Patients also reported anecdotes of the conversations, describing notifications that were left on answering machines or made on holidays.
The study authors acknowledged that some situations may require notification over the phone or in an impersonal location like an emergency room, but “having more than 20% of patients told their diagnosis in an impersonal manner suggests too many physicians are either unaware of or not practicing good communication skills,” they said. They recommended that the delivery of a cancer diagnosis be done face-to-face in a personal setting, last longer than 10 minutes, and include additional information beyond just the diagnosis, such as treatment options.
Patients who don’t get such a conversation may be not only more dissatisfied with the experience, but also more likely to change physicians after the diagnosis. More than half of the studied patients changed physicians—many because of a referral—but 10% gave poor communication as a reason for switching and 12% cited general dissatisfaction. The study was published online by the Journal of Clinical Oncology on July 6.
From ACP Hospitalist
.Send us your coding questions
Got a documentation or coding conundrum? Let ACP Hospitalist help you. Starting in August, Richard Pinson, FACP, will respond to selected questions from readers in his Coding Corner column. Email your questions to acphospitalist@acphospitalist.org. Please include your name, city and state, and professional credentials with your question.
Dr. Pinson, an internist for 30 years and a certified coding specialist, will also provide monthly documentation tips to help hospitalists accurately capture their patients' complexity of care—and ensure their hospital is reimbursed accordingly.
.Last chance: Suggest a colleague as a Top Hospitalist
ACP Hospitalist is seeking candidates for our third annual Top Hospitalists issue. We're looking for hospitalists who made notable contributions to the field in 2010, whether through exceptional clinical skills, improved work flow, patient safety, cost savings, leadership, mentorship or quality improvement.
Do you know a colleague who might qualify? Fill out our form and tell us who and why. All recommendations must be received by July 16, when our editorial advisory board will pick the winners. Top Hospitalists will be profiled in our November 2010 issue.
Cartoon caption contest
.Put words in our mouth
ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.
E-mail all entries to acphospitalist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.
About ACP HospitalistWeekly
ACP HospitalistWeekly is a weekly newsletter produced by the staff of ACP Hospitalist. Please forward any comments or suggestions to acphospitalist@acponline.org.
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Copyright 2010 by the American College of Physicians.
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